Rock and Scissors: Bloorview Kids Rehab Removes Paper for 100% Compliance

Achieving 100% compliance with a CPOE system is an achievement for any health care organization. This achievement is even more impressive in a special needs pediatric environment fraught with challenges related to dosing, growth rates, and very complicated orders. Bloorview Kids Rehab (Toronto, ON) is a pediatric teaching hospital that provides rehabilitative, respite, and complex continuing care to children with physical and developmental disability as well as children with complex medical needs. Bloorview has met these challenges head on--and achieved 100% compliance--by winning physicians' support.

As our first pediatric-oriented profile, we asked Bloorview's clinical information systems manager, Sheila Hops, RN, to explore how these factors influence CPOE implementation and usage, and to describe their strategies for achieving physician compliance.

MEDITECH: Do you think there's a difference between Canadian and U.S. providers in how they perceive CPOE?

Sheila Hops: That's an interesting question! I asked two clinicians and got two different answers. The physician who said yes feels that Canadian providers tend to look at CPOE more positively. They view it as a logical extension of the information age and focus on benefits such as communication clarity, minimization of error, and improved access.

One difference we've all noticed up here is that Canadian nurses are able to enter and sign off on nursing orders, while in most cases only physicians are able to sign off on orders in the U.S. At Bloorview, our nurses are the experts on the wound care and skin conditions, and are thus responsible for entering and signing off on orders. However, we had to "trick" the CPOE system by enabling nurses to sign off on their own orders in the "sign documents" routine.

M: How many physicians does Bloorview have?

SH: Bloorview has 12 physicians on staff and approximately 25 consultants who work in the clinics. We also have dentists on staff as well as residents, fellows, medical students, and dental students who are entering orders in the system.


M: How did they react to CPOE? Were they receptive?

SH: They were generally receptive to the change. Initially, the orders took longer to enter, and the physicians--who are caring for kids with complex conditions--really like the "restorable orders" feature, especially for the respite clients. They are doing really well and enter all orders electronically now. We've had no handwriting issues since the system went LIVE, and it does save time overall.


M: What number and/or percentage of physicians use MEDITECH for CPOE? Is it really 100% compliance? If so, to what do you attribute this success?

SH: Bloorview is 100% CPOE compliant. We attribute our success to support at all levels. In addition, the nurses are very good at reminding the physicians to enter their orders. However, because our physicians are not in the hospital during evenings and nights, and come in on the weekends only to do rounds, the nurses will enter physicians' orders placed by telephone during off hours. Some physicians use Citrix(R) to enter orders from home.


M: Did you use a third party, such as an outside consulting company, to assist you with physician adoption?

SH: We did work with a consultant to assist with dictionary building and to write NPR reports, but not for physician usage issues.


M: Does Bloorview have a physician adoption committee, physician champions, dedicated staff, or another structure in place to address physician usage?

SH: We have a terrific physician champion, Peter Rumney, MD, who has been involved with our clinical software since the selection process and was a member of the implementation team. Specifically, Dr. Rumney attends the Clinical Information Systems Committee meetings, acting as a liaison between the committee and the Medical Advisory Committee (MAC).

Also, Dr. Rumney attended training sessions on Order Entry and Patient Care System (Nursing) at MEDITECH, which enabled him to learn how the system works from a more global perspective. Now that he has an understanding of how other applications work, he's able to convey that to his peers.


M: How did you address process changes (i.e., changes to workflow) when implementing CPOE?

SH: During the CPOE implementation, the implementation team and the MAC discussed the advantages and disadvantages of processes and revised them whenever possible to ensure maximum clarity and efficiency. For example, there was no way to flag nurses that a medication order had been stopped, except by running a report. Nurses now must change the order status, which acknowledges receipt of the order.


M: Did you offer one-on-one training sessions for physicians?

SH: We offered one-on-one training sessions as well as group sessions of two or three physicians.


M: Did they find the system easy to use?

SH: The majority of physicians found the system pretty easy to use.


M: How did you encourage house physicians to use the system versus consultants? Did you use incentives? Did these incentives differ, depending on the physician's status with the hospital?

SH: We simply removed the paper order sheets and requisitions. Now the only time we use paper is for downtime. If the downtime is planned and there are no emergencies, our physicians choose to wait until the system is back up to enter medication orders. They prefer the system over paper.


M: Does Bloorview use a large number of order sets? Can you tell us a little about the process you used to create order sets?

SH: Our physicians use very few order sets, because each child has multiple conditions.


M: What was your go-LIVE like? Was it fairly smooth?

SH: Our go-LIVE was very smooth. We provided 'round the clock clinical I.T. support for the first three weeks, then cut back on support according to how things were going.

We also provided extra assistance for outpatient physicians on busy clinic days. We wanted to ensure that the recent computerization did not create frustration for physicians who did not have regular exposure to computer systems.


M: Did any particular group of physicians or specialists go LIVE first? How did you make this determination?

SH: No. The entire hospital went LIVE at the same time.


M: Did you have 24-hour coverage when you went LIVE?

SH: Yes. Twenty-four hour coverage is crucial!


M: Are there any specific challenges that pediatric hospitals--especially ones that deal with multiple conditions and other special needs--face when using CPOE?

SH: Dosing is the greatest challenge we face, because pediatric issues are not figured into system design, growth charts, and percentile calculations. The children we care for have multiple conditions, so order sets are very complicated, and the doses tend to be varied. It's very difficult to come up with standard dosing strings. Physicians enter instructions themselves and manually calculate dosages. Average dose ranges generally don't apply to our patients.

We are looking forward to the inclusion of growth charts in the 5.6 release, even though it's common for our patients to have conditions that affect their growth rates.


M: At what stage are you in your physician use of other MEDITECH software? Are physicians currently using results review, review of medication lists, e-signature of orders and/or reports, review of nursing data, review of notes from nursing/therapies, PACS image viewing from the EMR, CPOE, PCM Physician Desktop, PCM Physician Documentation, and Ambulatory Order Management?

SH: In addition to physicians entering their own orders, they check order histories and medication administration, review reports in the Enterprise Medical Record, and electronically sign their reports that are trascribed by our Health Data Resources staff.

Our neuro rehab physicians document on an acquired brain injury (ABI) Mayo-Portland Adaptability Inventory (MPAI) screen. This assessment tool completely replaces their stand-alone, aged, and time-consuming database. Now all the data flows to the Data Repository and is readily available for extensive research and reporting.


M: What number and/or percentage of physicians use the MEDITECH EMR for results review?

SH: Physicians use the EMR only to check reports. We don't have any labs on site.


M: What number and/or percentage of physicians use MEDITECH for other PCM functions (Physician Desktop, Physician Documentation, Ambulatory Order Management/prescription writing)?

SH: We aren't using PCM at this time.


M: What types of devices do the physicians use (e.g., wireless tablets, laptops on carts, and fixed devices)?

SH: Our physicians and other providers use COWs ("computers on wheels") and desktops at the nurses' stations. Our physician champion is currently testing a tablet device; our goal is to have all the physicians use tablets in the future. Bloorview opened a new building in February that has wireless capabilities in outside areas as well, so physicians will have a lot of freedom as far as accessibility is concerned.


M: Are there any lessons learned--positive or negative--from your physician experience so far that you feel would be beneficial to another organization starting a CPOE implementation?

SH: It's unreasonable to ask a physician to enter all orders into the computer except for medication orders. We recommend that organizations have every department and unit go LIVE all at once, and remove paper order sheets and requisitions. Supporting a hybrid environment is asking for failure.

Also, involving physicians in the selection process and communicating with the medical staff throughout the CPOE implementation encourage compliance, because physicians have a vested interest in the system's success.


M: Are there any particular factors specific to your situation that you feel enhanced or hindered the adoption of physician systems at your organization?

SH: Having a relatively small number of staff physicians seemed to enhance our situation.

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Do you have questions or comments about this article? Please e-mail them to Ann Marie Sennott. At the hospital's request, we ask that you refrain from contacting them directly, in the event that the same questions are raised by multiple readers.

 

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